09030126BUILDING DIVISION
PERMIT
BUILDING ADDRESS: PERMIT NO.
20975 VALLEY GREEN DR #266 TBD — TO BE DETERMINED 09030126
OWNER'S NAME: PERMIT ISSUE DATE
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ARCHITECT/ENGINEER:
LICENSED CONTRAUIUK'J UECLAKA1 TUN
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
License Class Lic. B
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (SM.
0 I, as owner of the property, or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale (See. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
buil will have the burden of proving that he did not build or improve for purpose of
sale
I. as owner of the property, am exclusively contracting with licensed contractors a
astroct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
ex^enm t o B& P C 'r tthT mason
\p� Date Ii�}�1
WORKER'S COMPENSATION DECLARATION \ 1
I hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
0 I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I cenify that in the performance of thework f which this permit is issued, I shall not
employ any person in any manner sostthicfk10 the Workers' Compensation
Laws of Callform D b G _
Applicant roc
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lender's Address
I certify that 1 have read this application and state that the above information is
correcL I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SS URC�T70NS.
a �W...� � h�...•.� `i � bit
Si atum of Applicant/Contractor Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
0 Yes 0 No
Will the applicant or future building occupant use equipment or devices which
1cmit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes DNo
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
m! cats whic ust bc m prior issuance of a Certificate of Oceypfcy.
6 1 b
Owner or authorized agent Date
CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB MECH
Job Description
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
E/M/P'S—SEE PERMIT #09030198 FOR PLAN CK
COMMENTS.
Sq. Ft. Floor Area
APN Number
32609041.266
Issued by
Re -roofs
Type of Roof
on
1
Type
Required Inspections
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new rr aterials for inspection.
Signature of Applicant
All roof coverings to be Class "W' or better
Date